Bismarck’s Health Insurance Act of 1883 established the first social health insurance system in the world. The German statutory health insurance system was built on the defining principles of solidarity and self-governance, and these principles have remained at the core of its continuous development for 135 years. A gradual expansion of population and benefits coverage has led to what is, in 2017, universal health coverage with a generous benefits package. The German health insurance system is not as cost-effective as in some of Germany’s neighbouring countries, which, given present expenditure levels, indicates a need to improve efficiency and value for patients.